Beautiful Savior Lutheran School Jr. Kindergarten Application Form

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Junior Kindergarten Application Form

- Children 4 years of age (turning 4 on or before December 31 of the current year)

- Children are required to be fully toilet trained

Birchdale Campus St. Mary's Campus
52 Birchdale Ave. 1541 St. Mary's Road
Winnipeg, MB R2H 1R9 Winnipeg, MB R2M 3V8

Child Information:

Child's Legal Name

Known commonly as:

Date of Birth

YYYY

Home Phone

Gender

Male

Female

Child's Primary Residence

Postal Code

2024-25

Baptismal Birthday

YYYY

Religion

Languages known/spoken

Home School Division

Location

Birchdale Campus, 52 Birchdale Ave, (runs Mon-Thurs 9:00-11:15 Sept to May)

Birchdale Jr. Kindergarten Days

4 Day
(M-Th)
9:00-11:15

Yes

St. Mary's Jr. Kindergarten Days

3 Day
(M/W/F)
1:00-3:15

Yes

5 Day
(M-F)
1:00-3:15

Yes

Mother Information:

Mother's Name

Mother's Cell Phone

Mother's Work Phone

Mother's Email

Mother's Residence: If different than child's primary address.

Mother's Name of work/school

Mother's Address of work/school

Occupation

Mother's Work/school Email

Father Information:

Father's Name

Father's Cell Phone

Fathers Work Phone

Father's Email

Father's Residence: If different than child's primary address

Father's Name of work/school

Father's Address work/school

Father's Work/school Email

Occupation

Custody Arrangements: Please complete if you do not live with child's other parent.

Living and Custody Arrangements

Child lives with:

Mother

Father

Guardian

If applicable, are there any separation agreements, court orders or other documents setting out custody arrangements for this child.
A copy must be provided to the school.

Yes

Are you aware that the childcare facility cannot ask the police to enforce custody arrangements if documents are not provided?

Yes

If applicable, are there any informal custody arrangements? Please describe:

Emergency Contact #1 (other than Mother/Father)

Name

Relationship to Child

Emergency Contact phone number

Emergency Contact work phone number

Address

Address of work/school

Work/school Email

Emergency Contact #2 (other than Mother/Father)

Name

Relationship to Child

Emergency Contact phone number

Emergency Contact work phone number

Address

Address of work/school

Work/school Email

Please list four other people who have permission to pick up your child from the childcare facility and/or school.

Medical Information:

Name of Doctor

Doctor's Phone Number

Address

Does your child have a life threatening allergy?

Yes

If yes, please indicate if your child has prescribed medicine:

Epipen

Inhaler

Personal Health Number

(9 digit)

Family Medical Number (6 Digets)

Family Medical Number

(6 digit)

Family Medical Number

(6 digit)

Family Medical Number

(6 digit)

Medical Information: Allergies

Does your child have allergies to food, animals, medications etc., describe if yes:

Are there any cultural, religious, or personal requirements or restrictions that we should be aware of. If yes describe:

Describe any physical, developmental, social, emotional or medical conditions relevant to the care of your child. Please be specific and give suggestions about how we can best accommodate these needs.

Nursery/Daycare Specific Information

Toilet Learning

Select all that apply.

completely potty trained

asks to use the toilet

uses underwear all day

will not use the toilet

uses diapers at all times

Nap

Children who do not nap rest on a cot for 30 minutes.

I want my child to nap

Other:

If you selected other, please explain.

Is there any other information that may help us facilitate your child's transition into the childcare facility? (special interests, specific likes/dislikes, major changes with family, etc.)?

Acknowledgements & Permission

I understand that BSLS is a Lutheran School & Childcare and that all classes are taught from the prospective of the Lutheran faith. I have read and accept the policies outlined in the school handbook available online at bsls.ca.

Yes

I have read and agree to abide by the BSLS School & Childcare Parent Policy Manual and the Code of Conduct available online at bsls.ca. I will speak to the administration regarding any concerns I may have.

Yes

BSLS publishes a phone directory, which includes names, address, phone number, and email address. The purpose is for ride sharing, birthday parties, and inviting a friend over. I/We wish to share our information in the school directory.

Yes

We give permission for candid and professional photos to be taken of our child either individually or in a group setting. The photos may be used for promotional material including brochures, bulletin inserts, pamphlets, social media, emails, videos, website, blogs, etc. but are not limited to these. Pictures will be in good taste and complimentary to school and child.

Yes

I will notify the school/facility of any changes to the information provided on this form.

Yes

I give permission for outings within our neighbourhood not requiring transportation in private or public vehicle.

Yes

I give permission for indirect supervision as described in the childcare parent manual.

Yes

I give permission to discuss relevant information about my child's day with school and childcare staff.

Yes

If applicable describe any arrangements for school-aged children to attend activities away from the school/childcare facility at your request:

Emergency Medical Transportation and Treatment:
If, at anytime, medical treatment is necessary due to a serious injury or sudden illness, I authorize the childcare facility and school to take whatever emergency measures deemed necessary for the protection of my child while in the care of the childcare facility and school. I give permission for my child to receive medical attention deemed necessary by my child's doctor or other medical personnel. I understand that this may involve transportation to the hospital in a private vehicle or ambulance. I understand that the facility will make every attempt to contact me and that expense incurred for such treatment, including ambulance fees, is my responsibility.

Yes

Verification